A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is C
Explanation
A. An allergic reaction is a possible response to medication, but it is not directly related to doubling the dosage.
B. Anaphylactic reaction is a severe and rapid allergic response; while possible, it is not the most likely consequence of an overdose in this context.
C. Poisoning is a likely concern when a client takes double the prescribed dosage of analgesics, especially if the medication has a narrow therapeutic index or is known to cause toxicity at high doses.
D. Sedative effects could occur depending on the analgesic used, but poisoning is a more pressing concern following an overdose.
Correct Answer is ["A","B","D","E"]
Explanation
A. Maintain good oral hygiene to minimize dry mouth is correct; good oral hygiene practices can help alleviate dry mouth, which is a common anticholinergic effect.
B. Void before taking the medication so urinary hesitation is less problematic is correct; this strategy can help manage urinary retention, another potential side effect of tricyclic antidepressants.
C. Avoid situations where bruising or lacerations are a possibility is incorrect; while caution is always advisable, this statement does not directly relate to anticholinergic effects.
D. Eat several small meals daily rather than three larger meals is correct; smaller meals can help mitigate gastrointestinal side effects and maintain steady blood sugar levels.
E. Use caution in situations where it may be possible to become overheated is correct; anticholinergic medications can impair thermoregulation, increasing the risk of heat-related illnesses.